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Fusunyan M, Medina M, Giambarberi L, Bajestan S. A Web-Based Educational Module Using Clinical Neuroscience to Deliver the Diagnosis of Functional Neurological Disorder. J Neuropsychiatry Clin Neurosci 2024; 36:166-171. [PMID: 38258378 DOI: 10.1176/appi.neuropsych.20230060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Neuroscience-based patient education has become an evidence-based strategy for enhancing chronic pain treatment. Advances in understanding the neuroscience of functional neurological disorder (FND) may allow similar approaches to be developed and disseminated to clinicians, given the public health need for greater provider awareness and expertise around the condition. Accordingly, the authors developed an online video module for clinicians that delivers neuroscience-based psychoeducation for FND and assessed whether the intervention would be associated with changes in clinicians' perception of FND patients and knowledge about the condition. The online intervention consisted of a 20-minute video module, including an 8-minute scripted role-play that modeled neuroscience-informed diagnosis delivery. Pre- and postintervention questionnaires were embedded into the online module and included a self-assessment of FND-related perceptions and knowledge and a multiple-choice assessment of retention of the neuroscience-based content. Wilcoxon signed-rank tests and McNemar's tests were used for statistical analyses. Of the 103 individuals who submitted surveys, 40 participants provided a complete data set from before and after the intervention. Following the intervention, self-assessment items showed respondents had significantly greater comfort with diagnosis delivery and treatment options and decreased negative perception of FND patients. The percentage of correct responses on a multiple-choice assessment regarding the functional neuroanatomy of FND was significantly increased. In summary, the online neuroscience-based educational intervention was effective for increasing clinician knowledge about FND and comfort with diagnosis delivery and treatment options. Implementing web-based formats may be a viable and cost-effective approach to disseminating knowledge and basic clinical skills in the care of patients with FND.
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Affiliation(s)
- Mark Fusunyan
- Department of Psychiatry, Santa Clara Valley Medical Center, San Jose, Calif. (Fusunyan); Kaiser Permanente, Sacramento, Calif. (Medina); Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, N.C. (Giambarberi); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan)
| | - Michel Medina
- Department of Psychiatry, Santa Clara Valley Medical Center, San Jose, Calif. (Fusunyan); Kaiser Permanente, Sacramento, Calif. (Medina); Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, N.C. (Giambarberi); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan)
| | - Luciana Giambarberi
- Department of Psychiatry, Santa Clara Valley Medical Center, San Jose, Calif. (Fusunyan); Kaiser Permanente, Sacramento, Calif. (Medina); Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, N.C. (Giambarberi); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan)
| | - Sepideh Bajestan
- Department of Psychiatry, Santa Clara Valley Medical Center, San Jose, Calif. (Fusunyan); Kaiser Permanente, Sacramento, Calif. (Medina); Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, N.C. (Giambarberi); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan)
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María Marta AP, Mercedes S, Alejandra Inés L, Cristina T, Camila W, Luciana DA, Guido Pablo K. Cultural issues: Perspectives and experiences of patients with dissociative seizures in Argentina. Seizure 2023; 106:101-109. [PMID: 36812680 DOI: 10.1016/j.seizure.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
PURPOSE To explore patients' subjective experience when receiving a diagnosis of Dissociative Seizures (DS) in Buenos Aires, Argentina, and their explanatory models about DS. METHOD A qualitative approach using semi-structured interviews was used to gain an in-depth and contextual understanding of the perspectives of 19 patients with DS. Data collection and analysis were followed by an inductive and interpretive approach informed by the principles of thematic analysis. RESULTS Four main themes emerged: 1) Reactions to the Diagnosis; 2) Ways of Naming the Disease; 3) Own Explanatory Models; 4) External Explanatory Models. CONCLUSIONS This information might help achieve an adequate knowledge of the local characteristics of patients with DS. Most patients could not express any emotions or considerations about being diagnosed with DS, and they related their seizures to a personal or social-emotional conflict and environmental stress; however, family members related patients' seizures to a biological cause. It is important to analyze cultural differences in patients with DS in order to develop appropriate interventions for this specific population.
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Affiliation(s)
- Areco Pico María Marta
- Buenos Aires University, Psychology School, Psychology School Research Institute National Council for Scientific and Technical Research (CONICET), Lavalle 2353 C1052AAA, Buenos Aires, Argentina.
| | - Sarudiansky Mercedes
- Buenos Aires University, Psychology School, Psychology School Research Institute National Council for Scientific and Technical Research (CONICET), Lavalle 2353 C1052AAA, Buenos Aires, Argentina
| | - Lanzillotti Alejandra Inés
- Buenos Aires University, Psychology School, Psychology School Research Institute National Council for Scientific and Technical Research (CONICET), Lavalle 2353 C1052AAA, Buenos Aires, Argentina
| | - Tenreyro Cristina
- Buenos Aires University, Psychology School, Psychology School Research Institute National Council for Scientific and Technical Research (CONICET), Lavalle 2353 C1052AAA, Buenos Aires, Argentina
| | - Wolfzun Camila
- Buenos Aires University, Psychology School, Psychology School Research Institute National Council for Scientific and Technical Research (CONICET), Lavalle 2353 C1052AAA, Buenos Aires, Argentina
| | - D' Alessio Luciana
- Buenos Aires University, Psychology School, Psychology School Research Institute National Council for Scientific and Technical Research (CONICET), Lavalle 2353 C1052AAA, Buenos Aires, Argentina; Buenos Aires University, Ramos Mejía Hospital, Epilepsy Center, Gral. Urquiza 609, C1221ADC, Buenos Aires, Argentina; Buenos Aires University, Medicine School, Cell Biology and Neuroscience Institute (IBCN)- National Council for Scientific and Technical Research (CONICET), Paraguay 2155, C1121 ABG, Buenos Aires, Argentina
| | - Korman Guido Pablo
- Buenos Aires University, Psychology School, Psychology School Research Institute National Council for Scientific and Technical Research (CONICET), Lavalle 2353 C1052AAA, Buenos Aires, Argentina
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3
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Nonepileptic attacks in patients with brain tumor-related epilepsy. Epilepsy Behav 2022; 129:108656. [PMID: 35305524 DOI: 10.1016/j.yebeh.2022.108656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/21/2022] [Accepted: 02/28/2022] [Indexed: 11/23/2022]
Abstract
Epileptic seizures are well recognized as a presenting symptom in patients with brain tumors, however much less is known about coexisting nonepileptic attack disorder (NEAD) in this population. Establishing a diagnosis of NEAD can be challenging, especially in those with concomitant epilepsy. Nonepileptic attack disorder is associated with a high rate of morbidity, often due to coexisting psychological factors which may require the input of multiple services. In an era where early aggressive management of tumors is enabling patients to live longer, the associated psychological impact of adjusting to physical disease is increasingly apparent. In this case series, we present a narrative summary of 9 patients referred to neurology with brain tumor-related epilepsy (BTRE) over a five-year period (2015-2020) who also experienced NEAD. We describe their tumor characteristics, treatment course, and factors potentially contributing to their presentation. We conducted a case note review of patients presenting to the epilepsy service with BTRE, in whom NEAD was diagnosed based on clinical features and correlation with their EEG. Patients ranged in age from 26 to 63 years. Two patients were diagnosed with grade 1, three with grade 2 and four with grade 3 tumors. Tumors localized to frontal or temporal regions in seven cases. All patients presented initially with BTRE and developed nonepileptic seizures subsequently. Four patients developed NEAD within 1 month of their tumor diagnosis. One patient developed NEAD 79 months following diagnosis. The diagnosis of NEAD was established in 8 patients by direct visualization of attacks (two during concomitant EEG recording). In the remaining patient, diagnosis was based on history (patient and witness). Six patients were diagnosed with concomitant low mood and/ or anxiety and three were commenced on antidepressant medication. At the time of last review, the predominant attacks were nonepileptic in all but one patient.
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Abstract
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
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Affiliation(s)
- Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Inselspital University Hospital, Bern, and Bern University, Bern, Switzerland
| | - David L Perez
- Divisions of Cognitive Behavioral Neurology and Neuropsychiatry, Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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O'Neal MA, Dworetzky BA, Baslet G. Functional neurological disorder: Engaging patients in treatment. Epilepsy Behav Rep 2021; 16:100499. [PMID: 34877516 PMCID: PMC8633865 DOI: 10.1016/j.ebr.2021.100499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 01/04/2023] Open
Abstract
Patients with a functional neurological disorder can be difficult to engage in treatment. The reasons for this are complex and may be related to physician, patient and health care system issues. Providers contribute to difficulties in treatment engagement by giving confusing explanations for the patient symptoms, stigmatizing patients, and not allowing patients time to voice their questions and concerns. Patient factors include a lack of engagement after an explanation of the diagnosis, resistance to treatment, family/work dynamics and prior negative experiences with the health care system. The scarcity of providers skilled in the treatment of functional neurological disorder is yet another hurdle. This article will define these barriers and discuss good clinical practices to help improve outcomes by tackling those challenges and discuss why for many patients an integrated care team approach is needed.
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Affiliation(s)
- Mary A O'Neal
- Department of Neurology, Brigham and Women's Hospital, United States
| | | | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, United States
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6
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O'Connor PJ, Reuber M. 'It's both challenging and probably the most rewarding work' - A qualitative study of psychological therapy provider's experiences of working with people with dissociative seizures. Epilepsy Behav 2021; 122:108156. [PMID: 34175664 DOI: 10.1016/j.yebeh.2021.108156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Limited research exists exploring the experiences of psychological therapy providers (PTPs) working with people with dissociative seizures (DS). PTPs play a key role in the treatment of DS, yet sit at the end of a long, often ineffective process of diagnosis and waiting before treatment can commence. This qualitative study was undertaken involving 12 PTPs from specialist DS services throughout England and Scotland. Semi-structured interviews were carried out, using thematic analysis to evaluate the data. Four key themes were identified, "neurological to psychological", "putting the person with DS at the center", "treatment process", and "issues and impact of therapy with patients with DS". The findings showed that an unclear and uncomprehended diagnosis, together with waiting times had a detrimental impact on patients at the starting point of therapy. People with DS were perceived as a heterogeneous group whose treatment needed to be individualized, using the PTPs' full 'toolkit' of modalities and techniques, with a focus on improving quality of life, rather than reducing seizures. The study highlighted the complexity for PTPs of working with major but also accumulated minor traumas, compounded by the impact of DS on both PTPs and treatment. The desire of PTPs to be totally patient-focused meant that individualized treatment was considered essential and meant that participants were doubtful about the possibility of compiling an effective manual for the psychological treatment for DS.
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Affiliation(s)
- Peri Jane O'Connor
- School of Health and Community Studies, Leeds Beckett University, City Campus, Leeds LS1 3HE, United Kingdom.
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom.
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Mameniškienė R, Puteikis K, Carrizosa-Moog J. Neurology specialists’ visual interpretation of psychogenic nonepileptic seizures: Contemplating their etiology and existing challenges. Seizure 2021; 90:175-181. [DOI: 10.1016/j.seizure.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/27/2020] [Accepted: 01/07/2021] [Indexed: 11/16/2022] Open
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Gras A, Wardrope A, Hirsch E, Asadi Pooya AA, Duncan R, Gigineishvili D, Hingray C, Kanemoto K, Ladino L, LaFrance WC, McGonigal A, Pretorius C, Valenti Hirsch P, Vidailhet P, Zhou D, Reuber M. Use of suggestive seizure manipulation methods in the investigation of patients with possible psychogenic nonepileptic seizures-An international ILAE survey. Epilepsia Open 2021; 6:472-482. [PMID: 34288577 PMCID: PMC8408588 DOI: 10.1002/epi4.12521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 02/05/2023] Open
Abstract
Video‐encephalographic (vEEG) seizure recordings make essential contributions to the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES). The yield of vEEG examinations can be increased through suggestive seizure manipulation (SSM) (ie, activation/provocation/cessation procedures), but its use has raised ethical concerns. In preparation for guidelines on the investigation of patients with PNES, the ILAE PNES Task Force carried out an international survey to investigate practices of and opinions about SSM. An online questionnaire was developed by the ILAE PNES Task Force. Questions were asked at clinical unit or individual respondent level. All ILAE chapters were encouraged to send questionnaires to their members. The survey was open from July 1, 2019, to August 31, 2019. A total of 487 clinicians from 411 units across 94 countries responded. Some form of SSM was used in 296/411 units (72.0%). Over 90% reported the use of verbal suggestion, over 80% the use of activation procedures also capable of eliciting epileptic activity (hyperventilation or photic stimulation). Only 26.3% of units used techniques specifically intended to provoke PNES (eg, saline injection). Fewer than 10% of units had established protocols for SSM, only 20% of units required written patient consent, in 12.2% of units patients received explicitly false information to provoke seizures. Clinicians using SSM tended to perceive no ethical problems, whereas those not using SSM were likely to have ethical concerns about these methods. We conclude that the use of invasive nocebo techniques intended to provoke PNES in diagnostic settings has declined, but SSM is commonly combined with activation procedures also capable of eliciting epileptic activity. While research suggests that openness about the use of PNES‐specific nocebo techniques does not reduce diagnostic yield, very few units have suggestion protocols or seek patient consent. This could be addressed through establishing consensus guidance for the practice of SSM.
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Affiliation(s)
- Adrien Gras
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France
| | - Alistair Wardrope
- Academic Neurology Unit, Royal Hallamshire Hospital, The University of Sheffield, Sheffield, UK.,Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Edouard Hirsch
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France.,Epilepsy Unit "Francis Rohmer", INSERM Federation de Médecine Translationelle, CHU-University Strasbourg, Strasbourg, France
| | - Ali A Asadi Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rod Duncan
- Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - David Gigineishvili
- Department of Neurology and Neurosurgery, Sarajashvili Institute of Neurology, Tbilisi State University, Tbilisi, Georgia
| | | | | | - Lady Ladino
- Neurology Section, Epilepsy Program, Hospital Pablo Tobon Uribe, Medellin, Colombia.,Universidad de Antioquia, Medellin, Colombia
| | - William Curt LaFrance
- Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, RI, USA.,Neurology and Psychiatry, Brown University, Providence, RI, USA
| | - Aileen McGonigal
- Clinical Neurophysiology and Epileptology Department, Hospital Timone, Marseille, France.,Institut de Neurosciences des Systèmes, Aix-Marseille Universite, Marseille, France
| | - Chrisma Pretorius
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | | | - Pierre Vidailhet
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France.,Fédèration de Medecine Translationelle, Université de Strasbourg, Strasbourg, France
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University West China Hospital, Chengdu, China
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, The University of Sheffield, Sheffield, UK.,Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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What do we know about non-epileptic seizures in adults with intellectual disability: A narrative review. Seizure 2021; 91:437-446. [PMID: 34332255 DOI: 10.1016/j.seizure.2021.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/05/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022] Open
Abstract
Psychogenic non-epileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with abnormal electrical activity in the brain. PNES are a heterogeneous entity and while there is increasing interest in the characterisation of PNES sub-groups, little is known about individuals with PNES who have an intellectual disability (ID). ID is a lifelong condition characterised by significant limitations in cognitive, social and practical skills. ID (commonly with comorbid epilepsy) has been identified as a risk factor for developing PNES. However, people with ID are often excluded from research in PNES. This has unfortunately resulted in a lack of evidence to help inform practice and policy for this population. This narrative review synthesises the currently available evidence in terms of the epidemiology, demographic and clinical profile of adults with PNES and ID. There is a particular focus on demographics, aetiological factors, PNES characteristics, diagnosis and treatment of the condition in this population. Throughout this article, we critique the existing evidence, discuss implications for clinical practice and highlight the need for further research and enquiry. What emerges from the evidence is that, even within the sub-group of those with ID, PNES are a heterogeneous condition. Individuals with ID and PNES are likely to present with diverse and complex needs requiring multidisciplinary care. This review is aimed at the broad range of healthcare professionals who may encounter this group. We hope that it will stimulate further discussion and research initiatives.
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Nicholson C, Edwards MJ, Carson AJ, Gardiner P, Golder D, Hayward K, Humblestone S, Jinadu H, Lumsden C, MacLean J, Main L, Macgregor L, Nielsen G, Oakley L, Price J, Ranford J, Ranu J, Sum E, Stone J. Occupational therapy consensus recommendations for functional neurological disorder. J Neurol Neurosurg Psychiatry 2020; 91:1037-1045. [PMID: 32732388 DOI: 10.1136/jnnp-2019-322281] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 03/12/2020] [Accepted: 04/01/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND People with functional neurological disorder (FND) are commonly seen by occupational therapists; however, there are limited descriptions in the literature about the type of interventions that are likely to be helpful. This document aims to address this issue by providing consensus recommendations for occupational therapy assessment and intervention. METHODS The recommendations were developed in four stages. Stage 1: an invitation was sent to occupational therapists with expertise in FND in different countries to complete two surveys exploring their opinions regarding best practice for assessment and interventions for FND. Stage 2: a face-to-face meeting of multidisciplinary clinical experts in FND discussed and debated the data from stage 1, aiming to achieve consensus on each issue. Stage 3: recommendations based on the meeting were drafted. Stage 4: successive drafts of recommendations were circulated among the multidisciplinary group until consensus was achieved. RESULTS We recommend that occupational therapy treatment for FND is based on a biopsychosocial aetiological framework. Education, rehabilitation within functional activity and the use of taught self-management strategies are central to occupational therapy intervention for FND. Several aspects of occupational therapy for FND are distinct from therapy for other neurological conditions. Examples to illustrate the recommendations are included within this document. CONCLUSIONS Occupational therapists have an integral role in the multidisciplinary management of people with FND. This document forms a starting point for research aiming to develop evidence-based occupational therapy interventions for people with FND.
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Affiliation(s)
- Clare Nicholson
- Department of Therapy Services, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Mark J Edwards
- Neurosciences Research Centre, University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Paula Gardiner
- Centre for Clinical Brain Services, University of Edinburgh, NHS Lothian, Edinburgh, UK
| | | | - Kate Hayward
- Department of Therapy Services, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Susan Humblestone
- Department of Neuropsychiatry, University College London Hospitals NHS Foundation Trust, National Hospital for Neurology & Neurosurgery, London, United Kingdom
| | - Helen Jinadu
- The Lishman Unit, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Carrie Lumsden
- Community Rehabilitation and Brain Injury Service, West Lothian Community Health and Care Partnership, Livingston, West Lothian, United Kingdom
| | - Julie MacLean
- Occupational Therapy Department, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Lynne Main
- Neurological rehabilitation out-patient services, Astley Ainslie Hospital, NHS Lothian, Edinburgh, Scotland, United Kingdom
| | - Lindsey Macgregor
- Falkirk Community Mental Health Service for Adults, NHS Forth Valley, Falkirk, Scotland, United Kingdom
| | - Glenn Nielsen
- Neurosciences Research Centre, University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Louise Oakley
- National Centre for Mental Health, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, United Kingdom
| | - Jason Price
- Department of Neuropsychology, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Jessica Ranford
- Occupational Therapy Department, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Jasbir Ranu
- Department of Therapy Services, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Ed Sum
- Integrated Community Neurology Team, East Coast Community Healthcare CIC, Lowestoft, United Kingdom
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Saxena A, Godena E, Maggio J, Perez DL. Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective. Neuropsychiatr Dis Treat 2020; 16:2119-2134. [PMID: 32982250 PMCID: PMC7509337 DOI: 10.2147/ndt.s247119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/26/2020] [Indexed: 12/17/2022] Open
Abstract
Functional neurological disorder (FND), a condition at the intersection of neurology and psychiatry, is a common and disabling outpatient referral to neurology and neuropsychiatry clinics. In this perspective article, we focus on the motor spectrum of FND (mFND), including individuals with functional movement disorders (FND-movt), functional limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative] seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within the neurologic and psychiatric communities to create "rule-in" diagnostic criteria, as well as thoughtful approaches to the clinical interview, delivery of the diagnosis and the development of a patient-centered treatment plan. These advances allow the promotion of good clinical practices in the outpatient assessment and management of mFND. Informed by the literature and our prior clinical experiences, we provide suggestions on how to evaluate individuals with suspected functional motor symptoms - including conducting sensitive psychiatric and psychosocial screenings. Additional sections discuss common "rule-in" neurological examination and semiologic signs of motor FND, as well as approaches to deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive behavioral therapy to examine relationships between symptoms, thoughts, behaviors and emotions are also discussed. Additional clinical research is needed to further refine and operationalize the assessment and management of mFND, across clinics, healthcare settings and countries.
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Affiliation(s)
- Aneeta Saxena
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Godena
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie Maggio
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - David L Perez
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neuropsychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Lehn A, Navaratnam D, Broughton M, Cheah V, Fenton A, Harm K, Owen D, Pun P. Functional neurological disorders: effective teaching for health professionals. BMJ Neurol Open 2020; 2:e000065. [PMID: 33681789 PMCID: PMC7903179 DOI: 10.1136/bmjno-2020-000065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/23/2020] [Accepted: 06/02/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives To provide an outline for the delivery of an educational course or lecture about functional neurological disorders (FND) that is directed towards health professionals with varying clinical knowledge and to highlight the educational efficacy that can be derived from a well-designed educational platform. Method Through multidisciplinary collaboration, a course designed to develop the skills for diagnosis and management of FND was created. Elements essential to the delivery of education are: (A) knowledge creation; (B) facilitating multidisciplinary cross-pollination; (C) listening to patients’ experiences; (D) communication skills practice; (E) case studies; (F) discipline specific mentoring; (G) establishing and addressing participant learning goals and (H) developing collegial and referral networks. Changes in participants’ knowledge and clinical practice were assessed via anonymous questionnaires before and after the course. Results Dramatically improved knowledge and confidence in assessment and management of people with FND has been found both immediately following the course as well as on 6-month follow-up. Conclusion It is possible to make real change in the understanding and management of medical and allied health clinicians working with people with FND with a low-cost intervention. Also, the development of educational networks and multidisciplinary collaboration can lead to the creation of therapeutic platforms for the diagnosis, management and advocacy of this patient group.
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Affiliation(s)
- Alexander Lehn
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,The University of Queensland Princess Alexandra Hospital Clinical School, Woolloongabba, Queensland, Australia
| | | | - Megan Broughton
- Brisbane Clinical Neuroscience Centre, Brisbane, Queensland, Australia
| | - Vince Cheah
- Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Alison Fenton
- Active Rehabilitation, Brisbane, Queensland, Australia
| | - Karl Harm
- Active Rehabilitation, Brisbane, Queensland, Australia
| | - Diana Owen
- Mater Education Centre, Brisbane, Queensland, Australia
| | - Paul Pun
- Emotional Health Unit, Mater Misericordiae Health Services Brisbane Ltd, Brisbane, Queensland, Australia
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Wardrope A, Wong S, McLaughlan J, Wolfe M, Oto M, Reuber M. Peri‐ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures. Epilepsia 2020; 61:758-765. [DOI: 10.1111/epi.16471] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Alistair Wardrope
- Sheffield Teaching Hospitals National Health Service Foundation Trust Royal Hallamshire Hospital Sheffield UK
| | - Siew Wong
- Sheffield Teaching Hospitals National Health Service Foundation Trust Royal Hallamshire Hospital Sheffield UK
| | | | - Maytal Wolfe
- William Quarrier Scottish Epilepsy Centre Glasgow UK
| | - Maria Oto
- William Quarrier Scottish Epilepsy Centre Glasgow UK
| | - Markus Reuber
- Sheffield Teaching Hospitals National Health Service Foundation Trust Royal Hallamshire Hospital Sheffield UK
- Academic Neurology Unit University of Sheffield Royal Hallamshire Hospital Sheffield UK
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14
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Ali F, Seri S, Cavanna AE. Levels of diagnostic certainty for nonepileptic attack disorder in the neuropsychiatry setting. Epilepsy Behav 2020; 103:106875. [PMID: 31937509 DOI: 10.1016/j.yebeh.2019.106875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022]
Abstract
Nonepileptic attack disorder (NEAD) is a medical condition commonly seen in neuropsychiatry services, often as a differential diagnosis of other neuropsychiatric conditions. Recommendations by the International League Against Epilepsy (ILAE) Nonepileptic Seizures Task Force propose a four-level hierarchical approach to the diagnosis of NEAD, based on history, witnessed event, and electroencephalographic (EEG) investigation. We set out to provide the first description of the diagnostic levels of patients with NEAD at a specialist neuropsychiatry clinic. Comprehensive clinical data from 148 consecutive patients with NEAD attending the specialist Neuropsychiatry Clinic run by a single Consultant in Behavioral Neurology were retrospectively reviewed. Patients with NEAD were primarily referred to neuropsychiatry by Consultant Neurologists (n = 94; 63.5%). The majority of patients were female (n = 108; 73.0%), with a disease duration of 7.9 years (standard deviation: 10.4). Anxiety was the most common comorbidity (n = 43; 26.7%). Categorization of patients according to the ILAE Nonepileptic Seizures Task Force criteria was mainly based on clinical features and EEG findings, as only 7 (4.7%) patients had attacks witnessed by a specialist. The largest diagnostic categories were 'possible' (n = 54; 36.5%) and 'clinically established' (n = 40; 27.0%), followed by 'documented' (n = 12; 8.1%) and 'probable' (n = 5; 3.4%). In 125 patients (84.4%), EEGs were performed. Selective serotonin reuptake inhibitors were the most frequently prescribed psychotropic medications (n = 48; 32.4%); 89 patients (60.1%) received behavioral therapy. There were no differences in pharmacological or behavioral management strategies across the patients categorized under different diagnostic levels. Patients with NEAD seen within neuropsychiatry settings are mainly assigned 'possible' and 'clinically established' levels of diagnostic certainty. Difficulty in capturing typical clinical events witnessed by an experienced clinician while on video-EEG can limit the clinical application of the 'documented' diagnostic level. If appropriate, active interventions can be implemented irrespective of diagnostic levels to minimize delays in the neuropsychiatric care pathways.
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Affiliation(s)
- Fizzah Ali
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK
| | - Stefano Seri
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK
| | - Andrea E Cavanna
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK; School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and UCL, London, UK.
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15
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Grünewald R. What are non-epileptic seizures, and why do people have them? Br J Hosp Med (Lond) 2019; 80:652-657. [PMID: 31707888 DOI: 10.12968/hmed.2019.80.11.652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Psychogenic non-epileptic seizures (dissociative seizures) are encountered commonly in emergency medicine and in acute medical wards. Although diagnosis is usually deferred to an expert in epilepsy, an understanding of the phenomenon is helpful in acute management of the patient and dealing with associated urgent safeguarding issues. This article describes a simple model of psychogenic non-epileptic seizures that is useful in clinical practice and helpful to staff, patients and their carers.
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Affiliation(s)
- Richard Grünewald
- Consultant Neurologist, Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2TA
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